E x t r a c o r p o re a l L i f e S u p p o r t

for Trauma
Joseph Hamera, MD*, Ashley Menne, MD

KEYWORDS
 ECMO  ARDS  Respiratory failure  ECPR

KEY POINTS
 Extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention for support of
trauma patients suffering from post-injury severe respiratory failure.
 With training, the technical skills of ECMO cannulation are accessible to most surgeons
and intensivists involved in the care of trauma patients.
 Using a systematic approach and with readily available bedside equipment, most ECMO
circuit troubleshooting can be accomplished bedside by a trained intensivist.
 In general, the risk of hemorrhage is not a contraindication to ECMO for trauma patients as
current technologies and data permit conservative or anticoagulation-free strategies.

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) has achieved widespread adoption

for a variety of medically refractory cardiac and pulmonary conditions. Although
most of the ECMO performed worldwide is for non-traumatic conditions, the first ap-
plications of ECMO in the adult population were for traumatic acute respiratory
distress syndrome (ARDS).1 Currently, despite expanding indications and increased
utilization, the application of ECMO for trauma represents less than 1% of all ECMO
runs.2 Despite the relatively infrequent presentation of trauma patients suitable for
ECMO, this therapy results in reasonable outcomes and has been suggested to
improve survival.3–7

Evidence and Epidemiology

In the most robust description of ECMO utilization to date, traumatic indications ac-
count for approximately 1% of all ECMO runs greater than 2(p3),3. However, the overall
trauma ECMO volumes increased substantially in the latter portion of the analysis, mir-
roring global trends in increasing the use of ECMO for non-traumatic disease after the

Department of Emergency Medicine, R Adams Cowley Shock Trauma Center, University of

Maryland School of Medicine, 22 South Greene Street, Baltimore MD 21201, USA
* Corresponding author. 155 N Fresno St, Fresno CA 93701.
E-mail address: [email protected]

Emerg Med Clin N Am 41 (2023) 89–100

https://doi.org/10.1016/j.emc.2022.09.012 emed.theclinics.com
0733-8627/23/ª 2022 Elsevier Inc. All rights reserved.

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90 Hamera & Menne

2009 H1N1 pandemic. Veno-venous (VV) ECMO was the most commonly used config-
uration of ECMO and the most common indication was therefore respiratory failure.2 A
minority of ECMO runs in trauma were configured as veno-arterial (VA) ECMO for
either traumatic cardiac failure or extracorporeal CPR (ECPR). The most common
traumatic indication for ECMO is respiratory failure resulting from blunt thoracic
trauma.3
Most published descriptions of ECMO in trauma report generally favorable prog-
nosis and comparable survival to non-traumatic ECMO.3 Propensity-matched
studies suggest superior survival when VV ECMO is used in appropriately selected
trauma patients with severe ARDS, but due to the rarity of the disease, heteroge-
neous patient population and ethical considerations randomized clinical trial data
do not exist.8,9

Extracorporeal Membrane Oxygenation Circuit Components

The ECMO circuit is a simplified and miniaturized version of the cardiopulmonary
bypass machine used in cardiac surgery. Recent developments in materials and
component engineering have greatly simplified the implantation of the ECMO circuit.
A conceptual diagram of the VA and VV ECMO circuits is shown in Fig. 1. Individual
programs will use equipment from various manufacturers and configure circuits
slightly differently; an example of one center’s equipment is shown in Fig. 2.
Blood is drained from the body through a large-diameter multistage cannula (known
commonly as either the drainage, outflow, or venous cannula). For most patients, this
is inserted into one of the femoral veins either percutaneously or by surgical cutdown
and advanced as close as possible to the right atrium (RA) and inferior vena cava (IVC)
junction.
Blood then travels through the tubing to the pump head. Most contemporary adult
pumps are magnetically suspended centrifugal flow rotary pumps. The operator sets
the RPM of the pump head and the flow depends on the adequate supply of blood to
the pump head as well as the pressure downstream. Even with modern magnetically

Fig. 1. ECMO conceptual circuit.

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 Extracorporeal Life Support for Trauma 91

Fig. 2. Example of ECMO Machinery33(A) Control Console (B) Heat Exchanger (C) Backup/
transport gas source (D) Oxygenator (E) Gas Blender (F) Emergency hand crank.

suspended pumps, a higher pump RPM will increase shear stress and thermal injury
resulting in increasingly unacceptable levels of hemolysis.
From the pump head blood then passes through the oxygenator. Modern oxygen-
ators consist of thousands of gas-porous microfiber tubules arranged in parallel to
provide a compact and efficient surface for gas exchange. Connected to the oxygen-
ator is the gas supply, which flows fresh gas through the air side of the membrane
lung. The rate of this gas flow is referred to as the “sweep.” Built into most oxygenators
is a heat exchanger.
After passing through the membrane lung, the blood path then goes into the return
cannula (also referred to as “arterial”) and back into the patient. In VV ECMO, this is
placed into the venous circulation, typically into the right internal jugular vein. In pe-
ripheral VA ECMO, the return cannula is typically placed into the femoral artery and
ends in the abdominal aorta, pumping blood into the central circulation in a retrograde
fashion.
Various customization options exist for circuit configuration. Of particular interest to
trauma, infusion limbs can be placed pre-pump allowing extremely rapid volume
administration. Renal replacement therapy can be performed directly through the cir-
cuit as well. Stopcocks placed at various points along the blood path allow infusion of
medications and sampling. Increased connectors within a circuit increase failure
points, increase complexity, increase infection risk, and increase the risk of blood sta-
sis and clotting. In general, while the connection points should be minimized as much

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92 Hamera & Menne

as practical, splicing in necessary access points later requires temporary discontinu-

ation of support and all of the accompanying risks.10 Balancing the merits of ensuring
the circuit is properly configured for any anticipated needs with the risk of excessively
complicated circuit design is an individualized decision.

Veno-Venous vs Veno-Arterial
The initiation of ECMO is a complex process requiring staff with various skills. First, the
surgical skills of cannulation are described below. Although the general principles will
be very familiar to emergency physicians and intensivists, there are several nuances
and cautions described for the placement of such large cannulae. Second, as
described above, the ECMO circuit is a formidably complex apparatus. Because of
this, specially qualified staff in the form of perfusionists and/or ECMO specialists
assist in the procedure to facilitate rapid and seamless initiation. Finally, ECMO initi-
ation is a time of rapid hemodynamic changes as tissue oxygen delivery is restored.
Careful monitoring and anticipation of hemodynamic changes by critical care nurses
and physicians are important to avoid complications. A general approach to the orga-
nization and responsibilities of a cannulation team is shown in Fig. 3.
The dominant form of ECMO used in the setting of trauma is VV, representing at
least 70% of the total ECMO runs. The indication for VV ECMO is pulmonary failure
resulting in an inability to provide adequate oxygenation with a mechanical ventilator,
most commonly in trauma caused by ARDS or tracheobronchial tree injury.2,3,7,9,11 No
specific criteria for trauma exist and the initiation criteria can be largely extrapolated
from the general ARDS population in combination with clinical judgment. As post-
traumatic ARDS is not commonly a hyperacute phenomenon. The mean time to initi-
ation of ECMO is measured in days.
A variety of configuration options exist for VV ECMO, of which the simplest is a
peripherally inserted two-cannula configuration. Access can be accomplished percu-
taneously with ultrasound guidance or via surgical cutdown. Percutaneous
ultrasound-guided technique is more commonly used and is a relatively straightfor-
ward elaboration on skills possessed by critical care and emergency physicians. There

- ultrasound
- sterile prep equipment
- Vascular access supplies
Cannulation Performs cannulation
- Drainage, return, +/- reperfusion
(quali ied operator(s))
cannulae
- suture and dressings

Perfusion
- primed ECMO circuit
Decision to Proceed (Perfusionist/ECMO Recieves machine side of cannulae and
with ECMO - appropriate backup devices and operation of ECMO circuit
specialist/other quali ied
equipment
provider)

- monitoring equipment - attention to hemodynamics and takes

Non-sterile support approproate corrective action
- resusciative medications (push
dose pressor, inoptropes. - assist with con irmation of drainage
(quali ied physician and
nursing) calcium, bicarbonate) cannula position
- Ultrasound with cardiac probe - coordiante downstream
low/destination for patient

Fig. 3. Diagram of the ECMO cannulation process. Starting at the decision to initiate ECMO,
the second level describes the three major task groups consisting of cannulating operators,
skilled circuit management, and resuscitation staff. The third level gives an abbreviated list
of equipment each role requires. The third level gives a general description of the tasks each
personnel group should be ready to perform to ensure a safe cannulation.

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 Extracorporeal Life Support for Trauma 93

are a few technical considerations relative to conventional central vascular access.

First, in the femoral vessels, specific cannulation of the common femoral vein (for
VV ECMO) or common femoral artery (for VA ECMO) is essential to ensure the safe ac-
commodation of the very large cannulae. Second, puncture at the 12-o’clock position
is likewise essential for the same reason. Finally, a relatively shallow angle of approach
is desired to avoid kinking and sharp turns with the less flexible dilators and cannulae
during insertion.12,13
The drainage cannula is typically inserted into the common femoral vein. Under ul-
trasound guidance, an initial vascular catheter or sheath is placed. After confirmation
of puncture of the appropriate vessel and satisfactory access technique, a long wire is
then passed through the sheath and ideally visualized passing through the intrahepatic
IVC with ultrasound or fluoroscopy. A generous skin incision is made and serial dilation
is performed to accommodate the multistage drainage cannula. Under real-time fluo-
roscopic or ultrasound guidance, the cannula is advanced to the cavoatrial junction
and secured.
The return cannula can be placed in either the right internal jugular or the contralat-
eral femoral vein. Subclavian positioning is uncommon due to the placement of a large
cannula in a non-compressible site, and the turns required to position in the left inter-
nal jugular are undesirable. The access technique is largely similar, with the caveat
that positioning is less particular as blood returned to the superior vena cava
(SVC) will be entrained by the right atrium. In general, some separation between the
drainage and return cannulae is desired, but close positioning does not guarantee
that recirculation will occur. ECMO support is then initiated.
Another option for VV ECMO is the dual lumen cannula, incorporating the drainage
and return into one device. These are typically placed in the right internal jugular vein.
The return lumen is directed out of one side of the cannula. To avoid recirculation or
vascular injury, the jet of the return blood must be carefully directed toward the
tricuspid valve. For this reason, transesophageal echo is often used during cannula-
tion to guide positioning. Care must be taken when securing and managing the can-
nula to prevent migration of cannula depth or rotational migration of the cannula.

Veno-Arterial Extracorporeal Membrane Oxygenation and Procedural Technique

For primary cardiac failure as a result of trauma, VA ECMO is the modality of choice.
VA ECMO in trauma carries higher mortality than VV ECMO in most series, likely as a
reflection of more acute and difficult-to-manage underlying injury such as cardiac
contusion or post-arrest myocardial dysfunction.13 VA ECMO is also a possible ther-
apy for cardiac arrest ECPR in the management of traumatic injuries. Because of the
high blood flow rates and efficient heat exchangers on ECMO circuits, VA ECMO is a
potent tool for managing cardiac arrest secondary to hypothermia.14
The initial cannulation for VA ECMO is broadly similar to the above-described steps
for VV ECMO cannulation. In place of a venous return cannula, a smaller diameter re-
turn cannula is usually placed in the femoral artery. Owing to the relatively large size of
the cannula, distal perfusion of the leg is at risk with an incidence of up to 10% to 70%
with the need for fasciotomy in up to 8%.15–17 The risk of ischemia is reduced by the
placement of a distal perfusion cannula (DPC). The decision to place DPC prophylac-
tically at the time of cannulation versus placement upon evidence of limb hypoperfu-
sion is program specific but is recommended by extracorporeal life support
organization (ELSO).13,18 Distal perfusion is accomplished with a smaller bore arterial
sheath (typically 6 French diameter) inserted antegrade into the superficial femoral ar-
tery (SFA). The arterial puncture site should be as close as possible to the cannula en-
try site to minimize the low-flow zone and avoid missing perfusion of branch arteries.

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94 Hamera & Menne

The DPC is attached to the arterial return cannula via a side port and the flow down the
DPC should be monitored to ensure that flow is adequate and that it is not excessive to
detract from delivery to the rest of the body.

Monitoring and Support on Extracorporeal Membrane Oxygenation

Patients on ECMO require continuous monitoring of their physiology, machine func-
tion, and constant attendance by trained staff. At a minimum, all patients should
have continuous telemetry monitoring, pulse oximetry, and invasive arterial blood
pressure monitoring.11,19 Serial radiographs should be followed to monitor the cannula
position and the development of other complications. Staff trained in the management
of system failure should be present at all times; depending on local program protocols,
this can include perfusionists, specifically trained ECMO specialists, or nursing staff
with demonstrated competency.
From a machinery perspective, at minimum continuous monitoring of rpm and flow
are necessary. Various newer generation systems can continuously monitor access
pressures and pre-oxygenator oxygen saturation, although with some marginal added
expense. Oxygenator function should be assessed in a protocolized manner with reg-
ular assessment of post-oxygenator blood gasses. If the oxygenator is failing to deliver
gas or is suspected to be responsible for a flow issue, a transmembrane pressure can
be displayed or transduced to evaluate for obstruction. The cannula position should
be assessed regularly to detect migration or failure of securing sutures.
For patients on VV ECMO, the adequacy of support is assessed by patient blood
gas and pulse oximetry. Blood gas analysis should be performed per protocol and
with clinical changes and adjustments should be made to sweep accordingly.11 On
VA ECMO, consideration should be given to advanced continuous hemodynamic
monitoring. A pulmonary artery catheter is especially useful in the weaning phase to
assess hemodynamic response as support is weaned. The right upper extremity arte-
rial monitoring is necessary to monitor for the north–south syndrome, a condition in
which poorly oxygenated blood moving through the native circulation is ejected by
the heart into the most proximal aortic branches supplying the myocardium and right
cerebral circulation.13,20
Specific physiologic targets on VV ECMO are not clearly defined by the medical
literature. In principle, the objective of VV ECMO is to deliver sufficient gas exchange
to sustain life, ideally while maintaining non-injurious ventilator settings.21,22 The ELSO
guidelines advise maintaining a SaO2 > 80% and suggest that a circuit blood flow of 50
to 80 mL/kg/min should be targeted to achieve this.20 At least initially, sweep gas flow
should be titrated to maintain normal pH and PCO2 (ELSO guidelines). Many centers
aim for a so-called ultra-lung protective strategy if possible, with plateau pressures
of 20 to 25 cmH2O, a driving pressure of 10, and tidal volumes well under 6 mL/kg/
IBW.11,22
Significant hemodynamic changes can be observed with the initiation of ECMO.
Exposure to the foreign substance of the ECMO circuit can cause an acute vasodila-
tory process similar to the systemic inflammatory response syndrome but it usually
abates rapidly. Alternatively or subsequently, with the initiation of extracorporeal sup-
port with improved oxygen delivery in the case of VV ECMO or restoration of flow with
VA support rapid improvement of hemodynamics is often seen and vigilant down-
titration of vasoactive support is indicated to avoid hypertensive complications. There
exists no consensus on hemoglobin targets for ECMO patients, but many centers
adopt the general critical care target of 7 mg/dL11.
Anticoagulation is preferred in all ECMO settings to avoid the risk of thromboembo-
lism. A loading dose is typically given around the time of cannulation as there is a high

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 Extracorporeal Life Support for Trauma 95

risk of stasis around the time of cannulation before the initiation of ECMO flow. Main-
tenance of anticoagulation during the ECMO run decreases the risk of thromboembo-
lism, prolongs circuit component life, and decreases the risk of catastrophic circuit
component clotting.23,24 However, VV ECMO embolization to the pulmonary circula-
tion poses less risk of catastrophic complication than systemic embolization risk in
VA ECMO. Additionally, the use of heparin-bonded circuits in contemporary equip-
ment decreases the risk of circuit failure. Collectively this means that VV ECMO can
be run safely without systemic anticoagulation for prolonged periods after a risk–
benefit analysis of particular use in the trauma population.25,26 However, most of
the trauma ECMO patients can be anticoagulated without clinically significant or sur-
gical bleeding.9,27

Extracorporeal Membrane Oxygenation Troubleshooting

The magnitude of support possible for circulation or oxygenation in an ECMO circuit is
proportional to the maximal achievable flow. Like a ventricular assist device, the pump
in an extracorporeal life support (ECLS) circuit can be thought of as preload depen-
dent and afterload sensitive. Recalling this principle can assist the bedside physician
in addressing low-flow situations that can be lethal in a patient dependent on extracor-
poreal support. Table 1 summarizes the causes of low-flow states and possible
corrective actions are described below.
The availability of blood in the venous side is often the rate-limiting component of
the overall ECMO circuit flow. The movement of blood through the circuit creates a
significant suction force that can result in the collapse of the IVC around the drainage
cannula. Therefore, positioning as much of the drainage cannula as possible within the
non-compressible intrahepatic IVC and cavoatrial junction is desirable. Ensuring
adequate intravascular volume is also essential to prevent the collapse of the IVC
around the drainage cannula and is of particular concern in the early phase of trauma.
On the other extreme and pertinent to the trauma population is the possibility of
increased intraabdominal pressure leading to extrinsic compression of the IVC and
flow starvation of the circuit. This can be because of over-resuscitation and third
spacing or mass effect from intraperitoneal or retroperitoneal hemorrhage. Kinking
or other restrictions of the drainage cannula at any point along its internal or

Table 1
Extracorporeal membrane oxygenation low-flow alarms

Low-Flow
Alarms Causes Corrective Action
Pre-pump Hypovolemia Resuscitation
Cannula kinking/obstruction Limb positioning, loosening of
constricting sutures or connectors
Misplaced cannula Cannula advancement/retraction
Increased pressure around cannula Rule out abdominal compartment
syndrome or mass occupying lesions
Low cardiac output Resuscitation
Inadequate drainage cannula size Cannula replacement
Pump Controller power failure Manual crank, replace unit/power
supply
Pump embolism/thrombosis Pump exchange
Post-pump Arterial hypertension (VA) Blood pressure management
Oxygenator clotting Oxygenator exchange
Inadequate return cannula size Cannula replacement

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96 Hamera & Menne

extracorporeal course can also result in circuit preload issues. Externally, this is often
observed as “chugging” (intermittent shaking motion of the cannula) and manifested
as transient or sustained flow drops. In the acute phase of a trauma ECLS run, simul-
taneous assessment of several possibilities should be undertaken. Particularly with
the trauma population, the intravascular volume should be assessed for hypovolemia
and corrected. Increased intrabdominal pressure may require either surgical decom-
pression or evacuation. External circuit components should be evaluated for kinking,
restrictive connectors, or excessively tight securing sutures. Ensure appropriate posi-
tioning of the limb where the drainage cannula is located (often an individualized trial
and error process). Appropriate positioning of the drainage cannula should be verified.
Reference to daily measurements of external cannula length or chest radiograph can
be of use. A bedside ultrasound, particularly the subxiphoid/IVC window, can visualize
the hyperechoic cannula tip in the appropriate position. Drainage cannulae that are too
small or too large for the patient can either restrict flow or increase predilection for
chugging and can be replaced if technically feasible. If unsuitable, a second drainage
cannula can be placed.20
Flow decreases can also be seen due to issues intrinsic to the pump. Pump failure
can be caused by an interruption of the power supply or failure of the control console.
All ECLS circuits should have a mechanism for docking the pump to a manual hand
crank in the event of catastrophic failure. Mechanical failure of the pump or embolized
thrombus entrainment can also cause abrupt pump failure requiring emergency pump
replacement. In situ thrombus development will cause a more gradual degradation in
pump efficiency and also necessitates replacement.
The final class of flow failure on ECMO relates to increased pump afterload. In both
VV and VA circuits, this can be caused by clot formation in the oxygenator or mechan-
ical kinking of any other downstream component. In these cases, the oxygenator can
be changed and any restricting elements removed. In VA ECMO, elevated arterial
blood pressure will result in increased pump afterload and decreased extracorporeal
flow. The use of vasodilators targeting a normal mean arterial pressure may be neces-
sary to restore extracorporeal flow in hypertensive patients.
Hypoxemia on VV ECMO despite adequate flow raises many possibilities. As
described above, extracorporeal oxygenation potential depends on blood flow
through the ECMO circuit. The first possibility, when confronted with a hypoxemic
ECMO patient, is that the circuit flow is insufficient for the patient’s needs. If the
flow achieved has dropped below what the patient had previously maintained, the
above evaluation should be performed to diagnose the cause of decreased flows.
There are two significant additional issues while on VV ECMO: recirculation and
insufficient capture. Recirculation occurs when blood from the return limb is
entrained by the drainage cannula instead of going through the right ventricle (RV)
and on through the lungs to the systemic circulation. This can be diagnosed by either
observation of failure of color change between the drainage and return tubing or by
an inappropriately high oxygen saturation on a pre-oxygenator blood gas. The first
step in management is often counterintuitively lowering the pump rpm, which should
decrease the suction pressure on the drainage limb, and therefore, decrease entrain-
ment of the arterialized blood. As long as the patient oxygenates appropriately with
the reduced flow, no further action is required. If this fails, retraction of the cannula to
increase separation is usually indicated. Another possibility, especially in recovering
or infected trauma patients with healthy hearts, is decreased capture fraction. Even
well-functioning ECMO circuits seldom flow greater than approximately 6 L per min-
ute; cardiac output in excess of the ECMO circuit flow is functionally shunted if there
is negligible native lung function. Generally, a ratio of ECMO flow to total cardiac

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 Extracorporeal Life Support for Trauma 97

output above 0.6 will provide sufficient oxygen.21,28The first objective is to ascertain
appropriate oxygen targets; patients on ECMO will often tolerate lower oxygen satu-
ration. Next, in cases where perfusion is adequate, suppression of cardiac output
with either anxiolysis or beta-blockade is an option. These interventions have a
dual effect of decreasing oxygen demand.
The lifespan of individual ECMO circuit components is not clearly defined or consis-
tent. The most vulnerable component of the circuit to failure is the oxygenator, which
by virtue of the turbulent flow sectors created as blood partitions between the micro-
fibers and the numerous internal small channels with resultant high surface area to vol-
ume ratio is prone to macroscopic and microscopic clot formation and degradation
over time. Visual inspection may reveal clots, but these usually do not mandate inter-
vention unless significant and on the arterialized side of the oxygenator. The function
of an oxygenator can be interrogated by measurement of post-oxygenator blood gas
and measurement of transmembrane pressure. A decrease of the post-oxygenator
PO2 below a certain threshold or elevation of the transmembrane pressure suggests
oxygenator failure and an indication for replacement. Depending on the circuit/manu-
facturer, the oxygenator can be replaced individually or may be replaced as a unit with
the pump head.
Catastrophic failure of ECMO circuit components is uncommon but potentially le-
thal. Despite the track record of safe and prolonged support, ECMO circuit compo-
nents are not rated for indefinite support.29 Catastrophic failure would be most
easily addressed by the replacement of the entire circuit to simplify the process. Fail-
ures at the cannula level mandate emergent re-cannulation.
Future Directions
Selective aortic arch perfusion (SAAP) is an underdeveloped extracorporeal support
technique with applications in medical and traumatic cardiac arrest. SAAP is a balloon
catheter inserted via the femoral artery retrograde into the aorta. The tip of the catheter
contains a large bore infusion port. When inflated, the device functions much like a
resuscitative balloon occlusion of the aorta with added functionality for infusion of va-
soactives and blood products targeting the central circulation.30 SAAP has been
assessed in several animal models of traumatic cardiac arrest with good outcomes
but has yet to be deployed in humans.
Emergency preservation and resuscitation is another experimental concept in the
early pilot phase. This procedure borrows from the data and experience with deep hy-
pothermic circulatory arrest in cardiac surgery and involves either open or endovascu-
lar descending thoracic aortic cross-clamp followed by clamshell thoracotomy to
allow the introduction of a cannula directly into the proximal aorta. Ice cold fluid is
administered to achieve a profoundly low upper body temperature of 10 Celsius
and the patient is placed on full cardiopulmonary bypass.31 Expectations based on an-
imal data suggest that up to 2 hours of cold ischemic time can then be well tolerated
while definitive hemorrhage control is obtained with good neurologic outcome.32
Each of these described experimental technologies should not be attempted
outside of research protocols.

CLINICS CARE POINTS

 Trauma surgeons and non-surgical experienced physicians can, within an appropriately

supported program, use ECMO to rescue refractory respiratory and circulatory failure in
trauma patients.

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98 Hamera & Menne

 ECMO cannulation can be accomplished bedside either as the preferred technique or in

patients too unstable to move.
 Cannulation requires knowledgeable and skilled vascular access skills to ensure an
appropriate approach and entry point to the target vessels.
 VV ECMO can be safely managed at least temporarily with minimal or no anticoagulation,
and as such, trauma is not a contraindication to ECMO.
 Maintaining adequate flow through the ECMO circuit is the most essential task of
maintaining adequate extracorporeal support while on ECMO.

DISCLOSURE

The authors have nothing to disclose.

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